Basic Information
| Provider Information | |||||||||
| NPI: | 1225088255 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES A CANNON JR MEMORIAL HOSPITAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | APPALACHIAN REGIONAL HEALTHCARE SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 FURMAN RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624111 | ||||||||
| FaxNumber: | 8282624157 | ||||||||
| Practice Location | |||||||||
| Address1: | 434 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | LINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286460787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624133 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/18/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ETTA | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP MEDICAL STAFF RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8282624133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | APPALACHIAN REGIONAL HEALTHCARE SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 282NC0060X | H0037 | NC | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 00103 | 01 | NC | NC BLUE CROSS ACUTE CARE | OTHER | 0340005 | 05 | TN | MEDICAID | 3401323 | 05 | NC | MEDICAID | 6065 | 05 | TN | MEDICAID | 152168200 | 01 | NC | OWCP ACUTE CARE PROV NUMB | OTHER | 5070877 | 01 | NC | UNITED HEALTHCARE ACUTE # | OTHER | 290780 | 01 | NC | MAMSI ACUTE CARE PROV NUM | OTHER |